Family Doctor agreement submit form

Benefits of having a Family Doctor:

1，Free review of checkup reports once a year.

2，Free prescription fee for medication refills.

3，Free follow up calls.

4，Priority given for appointments and referral services.

Would you recommend this FM physician to your friends / family？

★ ★ ★ ★ ★ ★ ★ ★ ★ ★

Are you satisfied with your visit today?

Satisfied

Unsatisfied

Do you agree to have this doctor become your PCP doctor?

Agree

Disagree

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